10.03.2010

Logo

This week I'll be speaking to pre-physical therapy students at Messiah College about interpersonal skills in the clinic. I'm certainly not the expert on this, but chose this topic because:

1) It's relevant for all health care providers and especially so for this profession. It applies on a daily basis whether you're a PT or intern or volunteer. I succeed and fail with this stuff every day.

2) It's not another academic fact binge. They're probably getting their fill during all the rest of the time they have to sit and listen to middle aged people talk.

3) Although things may have changed since I was in school, interpersonal skills don't get much coverage, at least not practical, realistic, honest attention.

So for 30 or so hopefully not too boring minutes, it's gonna go a little something like this...

- - - - -The American Physical Therapy Association attempts to summarize the essence of physical therapy with a little blurb under the APTA logo. Has anyone seen it?

"The science of healing. The art of caring."

I think it's great. I REALLY like that motto. What therapist (or any health care provider) wouldn’t do well to take it seriously and examine themselves by it?

How do you feel about "art" and "caring" being put up there with equal status of "science" and "healing?"

Things may have changed a lot since I was in school almost 10 years ago, but I would bet my gluteals that all of you can guess if it was "caring" or "science" that occupied 99 percent of training. We heard a lot about ethics and codes of conduct, but nobody even tried to teach us how to care. I can understand why it's that way, and I'm not so sure it could be any other way (especially at a state school).

The assumption, I guess, is that you do care. You want to help people, right? But I can tell you that when you're put in any kind of competitive environment; when you're asked to walk the line between efficiency and quality of care; when you're up against a schedule full of folks with arthritis on a rainy day and everyone is achy, the caring isn't always foremost on your mind.

Art, really? What professor or clinical expert confesses to art? Are you going to mention your artistic ability during entrance interviews? Maybe you should.

In defense of science

There's no substitute for clinical competence. All else being equal, what person with a miserably sore knee would pass on a top clinician with poor bedside manner in favor of a kind chap who uses the Magic 8 Ball in his clinical decision making?

There’s a reason why much of our weight is planted on science while art barely gets a toe touch. We believe that PT can help many people function and that it makes sense economically. We believe that our methods are reliable and valid. But believing does not make these things true. After all, therapists have a vested interest in doing a good job, even if their “caring” only concerns themselves.

Art and caring are soft and non empirical. Neuroscientists may track electrical activity in the brain that are vague evidence of some thoughts, but who can calculate caring? You can quantify caring no more than you can see a ground reaction force. Employers and insurance companies don't reimburse you for caring.

The caring of science

Or do they?

The problem with the above scenario is that all else is not equal. The bridge between science and caring is the reality of two whole people. Go ahead over to Medline and search "bedside manner." Notice the number of studies that pop up, and the trouble they have with even defining, much less studying bedside manner in purely humanistic terms.

Caring isn’t just the spoonful of sugar that makes the medicine go down. It's a vital ingredient in the medicine itself. It’s science that now confirms and helps us understand the complex interaction between the body and mind. Among many mysteries, we now have an inkling to how experience, expectation, stress, and other purely mental “events” have an effect on pain perception and other facets of healing.

So we're learning and practicing in terms of clinical pathways, prediction rules, and confidence intervals. And the patients...nobody cares. Really, nobody cares about how much you know until they know how much you care. In a decade of treating patients, I can tell you that people, whether they want to admit it or not, care far more about how you make them feel as a person and how you satisfy their personal needs than they do about how well written and effective your treatments are. Just watch. You don't need an MRI to see that.

So care, damn it

If healing and caring are a package deal that were never meant to be sold separately, what are some practical suggestions for caring?

1) Stand on evidence, yes. You have to. But stand at the edge, where you can still reach over and wrap both arms around a whole person in need of some caring (the hug may be metaphorical at times).

2) Our caring should have feet. External validity, if you will. Does your life generally validate your work? Do you highlight research journals on weekends and catch yourself analyzing the gait of strangers? Does your physical appearance affirm that you know something about body maintenance and repair? Do you offer your services to your closest friends and your own mom for no other reason than because you think you can help?

3) Maybe you need to seek or create an environment that leaves a little room for art. This may be difficult to do as a student, but again, watch and learn. I'm certainly aware of clinical models that have PTs "treating" four patients every hour, many of those patients going out and telling their friends that rehab doesn't work.

4) Do you care enough to look them in the eye and listen? Part of INTERACTING "in a confident yet respectful manner" entails your mouth being shut. Wisdom knows how to pull off engaged listening without getting caught up hearing about a sisters sons cat for the third time. I could certainly use some help here. But I can say that if your caring is mostly just about your competitive drive and need to defend your chosen profession and pay the bills, the clients can tell. And sooner or later, so will your "outcomes."

5) It all counts-the type of person you are developing into along the way toward your PT license. Credentialing exams don't test you for caring, by the way. I think that seeing PT as a calling is the only route to this caring. Otherwise, it’s just a bunch of knees and backs and shoulders. I suppose it's possible to get by that way, but it can't be very easy and rewarding. Or fun.

The logo captures far more than the academics of PT. I’m humbled and challenged.